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CORRECTED TRANSCRIPT OF ORAL EVIDENCE
To be published as HC 1048 -i
House of COMMONS
TAKEN BEFORE the
tuesday 17 may 2011
professor david hunter, professor lindsey davies, angela mawle and dr fiona sim
Evidence heard in Public Questions 1 - 69
USE OF THE TRANSCRIPT
This is a corrected transcript of evidence taken in public and reported to the House. The transcript has been placed on the internet on the authority of the Committee, and copies have been made available by the Vote Office for the use of Members and others.
Taken before the Health Committee
on Tuesday 17 May 2011
Mr Stephen Dorrell (Chair)
Grahame M. Morris
Mr Virendra Sharma
Dr Sarah Wollaston
Examination of Witnesses
Witnesses: Professor David Hunter, Director, Centre for Public Policy and Health, Durham University, Professor Lindsey Davies, President, Faculty of Public Health, Angela Mawle, Chief Executive, UK Public Health Association, and Dr Fiona Sim, Vice Chair, Royal Society for Public Health, gave evidence.
Q1 Chair: Thank you very much for coming along this morning. I would like to open the evidence session by asking you to introduce yourselves very briefly and to tell us a bit about the organisations you come from and how they fit into the public health world.
Angela Mawle: I am Angela Mawle, Chief Executive of the UK Public Health Association. We are a multidisciplinary group and we represent public health workers across the whole sector: local authorities, NHS, PCTs, community activists and retired people, who pay only £5. They all have a common mission of promoting sustainable development, combating health inequalities and combating antihealth forces, which we say is the tobacco industry and perhaps the food industry-those sorts of things. We are broad based. We don’t have a lot of money and we do what we can with the resources we have, but we are very multidisciplinary.
Professor Davies: I am Lindsey Davies, the President of the UK Faculty of Public Health. We represent specialists in public health. All our members are qualified specialists in public health. We are the body that sets standards for public health practice training in the UK and we also do a lot of public health advocacy work.
Professor Hunter: I am David Hunter, Professor of Health Policy and Management at Durham University. I am the academic here. I head up a little centre called the Centre for Public Policy and Health, which undertakes research on public health, and we have completed two major studies recently, one on partnership working in public health and the other on public health governance in primary care. However, I do get involved in the real world as well. I was a former chair of the UKPHA until a couple of years ago and I am a nonexecutive director of NICE, with particular responsibility for public health, which is a growing area of its activity.
Dr Sim: I am Fiona Sim, the Vice Chairman of the Royal Society for Public Health. It is a very wellestablished, centuriesold organisation that has merged over the years from several predecessor organisations. It is a third sector body with a broad membership of people who are interested in public health, from specialists in public health and consultants, people working in local government, in environmental health and nutrition, in leisure services and so on, through to interested individuals and health professionals, including GPs, pharmacists, dentists and so on. It has a number of qualifications, mostly in food hygiene and environmental health, and a strong advocacy role.
Q2 Chair: Thank you very much.
This is the first public evidence session of an inquiry we are doing on the management of public health and the opportunities for public health, which is obviously against the background of the Health and Social Care Bill and the Government’s proposed changes to the way in which health care is managed. The first question is probably best addressed, at least in the first instance, to Professor Hunter. It would be very helpful to us to understand both how public health accountability currently is supposed to work-where the strengths and weaknesses, in your view, of that process are-and then how you think those accountability structures are changed by the Government’s proposals-how you reflect on those. That is quite a wide range of questions, but it would be helpful to get all those issues on the table at the beginning of the discussion rather than them coming up in an unstructured way during the session. Perhaps we can start with Professor Hunter.
Professor Hunter: As you say, it is a tall order, but I will try to be succinct. First of all, debates have raged over what we mean by (a) public health and (b) the public health
system. However, I think most people would agree that it is a broad based and complex system. On one level, it affects all that happens in public policy and in the organised efforts of society, as Acheson put it, to improve the public’s health. It therefore embraces what happens in the NHS, in local government, in organisations outside government, including in the private third sectors. Therefore, the boundaries are a problem.
Public health at one level is about everything that affects our lives, and, arguably, that is a strength.
FOOTNOTE BY WITNESS: Public health challenges, including obesity, alcohol misuse, sexual health, are what might be termed ‘wicked’ problems, that is, they are complex, cut across multiple practitioners and organisations, and defy easy or simple solutions. They do not belong to one sector or agency but require cross-boundary working usually conducted by partnerships of one sort or another.
The difficulty, when it comes to accountability and governance, is that the public health function has a very broad, allencompassing, allinclusive definition that doesn’t take one very far in terms of effectively holding those parties whose activities impact on the public’s health to account. Generally, there is agreement that the public health community comprises: specialists in public health, who, at the moment, primarily work in the NHS; people working in public health practice, who, again, primarily work in the NHS but also in local government; and then the wider public health-people whose work does touch on public health issues but who would not describe themselves as public health practitioners. At the moment, the public health function is led by the NHS, both locally and nationally. I say "at the moment" because I am not sure what is left of the previous NHS because things are happening to change that now but, in terms of primary care trusts and so on, it does have the principal responsibility for public health.
It is also probably useful to say that public health comprises what is generally acknowledged to be three domains: health improvement, health protection and health service development. Whether one agrees that those domains should all come under one specialty or one individual director of public health is arguable, but the public health community generally accepts those three domains as a typology for describing the functions. The controversy-and one of the reasons for the changes being proposed by the government-is that the health improvement part of that agenda has more to do with what happens outside the NHS than inside in terms of improving the public’s health, addressing the social determinants of health and tackling health inequalities. Arguably, that is a nonNHS core function, yet the lead for it has been invested in the NHS since 1974, and that has been a source of tension. It is conceded-and the move towards appointing joint director of public health posts over the last few years is an acknowledgement of this -that local government has to be a central part of that arrangement. Therefore, partnership working is very important and the whole previous structure of local area agreements and local strategic partnerships was an attempt to embrace all that.
Health protection is split between the NHS, ocal government and nationally, although the NHS has a key though not exclusive role . The wider public health, again, lies outside the NHS for the most part and embraces pretty well everything that local government and other agencies do. Accountability is mixed, in terms of the lead role, at the moment. Prior to joint DsPH posts being introduced a few years ago, it came through the DPH, who was accountable, initially, to the NHS. Now the joint posts held by DsPH are accountable to both local authorities and the NHS. That arrangement has worked variably across the country in terms of the degree of "jointness" and integration. It is, therefore, a bit mixed, messy and uneven across the country .
The Government’s move to make local government the lead agency for public health is a recognition, in some quarters, that public health’s natural home lies in local government. There is a strong view that a mistake was made in 1974 in transferring public health out of local government. The Health Committee report in 2001-10 years ago-which I remember well as I was involved in it, argued at length over whether local government should assume the lead role for public health and take public health back from the NHS or whether it made more sense to leave public health where it was and avoid a major organisational upheaval. It was accepted that major structural change should be avoided -why mess around with structures?-and that far more important was the function itself, ensuring the necessary governance structures were in place and holding people to account for what they achieved. Structural rejigging, the Committee conceded, would be detrimental, unhelpful and a distraction.
This Government have decided to restore the lead role for public health in local government. While the move was initially widely welcomed, in the last few months we have seen some retreat from that position and growing concerns that what might have been seen to be important gains in the NHS for public health might be lost if local government were to take a lead role at a time when local government itself is under severe pressure financially. I could go on.
Q3 Chair: In terms of where accountability rests in the proposed structure, if the Bill goes through in its current form, is it clear in your mind that lead responsibility rests in local government?
Professor Hunter: I think it is confused, to be honest. Part of it – the health improvement component of accountability – lies there and part of it – the health protection component – lies with the new entity within the Department of Health-Public Health England-and the Secretary of State for Health. There is dual accountability. For local government that is a problem, because to have somebody in their chief officer ranks who is simultaneously accountable locally and to a central Department Minister- in this case the Secretary of State for Health-is a problem. Professional accountability to the CMO would be acceptable. The problem would be having a senior local government officer jointly accountable to the Secretary of State for Health at the centre and locally to the chief executive of the local authority. That is a red line that local government would find it difficult to cross. It would set a precedent that local government would find it hard to accept.
Q4 Chair: That remains, in your mind, an unresolved difficulty about the proposals at this moment.
Professor Hunter: Definitely, yes.
Chair: That is helpful.
Q5 Valerie Vaz: Some public health experts have been saying that Public Health England is not the proper way to deal with public health and that there needs to be a population view. What is your view about some of the proposals that have come through about a special health authority that has only public health?
Professor Hunter: I can see the appeal, but there are drawbacks. In terms of what the Government wanted to achieve, turning the Department of Health into a health department-not an illhealth department, because the NHS would be responsible to the proposed commissioning board would be hived off. If you take public health out of the Department of Health and put it into a special health authority as some critics of the proposed changes favour, I am not quite sure what is left-you have got virtually nothing except the Minister, or several Ministers, and no function. I am not clear how that would work in practice, plus there is the fact that hivedoff agencies do have problems engaging at the top table and shaping and influencing policy since they tend to be at one remove from these internal systems and processes. If you look at what happened in New Zealand, for example, some years ago when they had an independent Public Health Commission, it began to flex its muscles and raise controversial issues and, in the end, was abolished for being too critical of government. It had no way of fighting back. If you want to influence and shape policy, being at the top table and part of the system, however messy and uncomfortable it may be, is preferable to being hived off to a nextsteps agency where you may not have that degree of traction on the system.
Q6 Valerie Vaz: The way I understand it is that there would be accountability to the Secretary of State, but they could be left to get on with their work. What do the others think?
Professor Davies: We have a rather different view in terms of Public Health England. We think that it is fundamentally important for public confidence that people who are practising public health are able to speak in a professional way and in a way that the public and professionals can have confidence that they are speaking from their own authoritative judgment on the evidence and drawing on their own experience, as well as that there isn’t any overlay that relates to the organisation that happens to employ them. Obviously, that is a challenge.
As public health people, we are all about wanting to make change, to drive things and to be influential. Sometimes you have to make a choice between being able to influence internally in your organisation and being able to speak freely externally. I made that choice, myself, when I moved from a health authority years ago into the Department of Health as a civil servant. I have been back out and forwards and I have spent a lot of time in both ways of working over the years. I know perfectly well how easy it is-or isn’t-to speak freely as a civil servant on matters of public health. You can say some things but, naturally, you have to be sensitive to where you are coming from. On the other hand, as a director of public health at one remove from the Government, you can and should speak from professional expertise and understanding.
If Public Health England is set up as planned at the moment-as one more directorate of the Department of Health-it will lose any opportunity to speak influentially and authoritatively to the public about important health matters. I think that that would be a huge loss. Also, if it is part of the Department of Health, it will not be able to generate the income that, for example, the HPA-the Health Protection Agency-can do from research and other ways that subsidises a lot of its other public health activity.
The model we would see for Public Health England would be that it is set up, ideally, as an NHS body, but, failing that, as an Executive agency of the Department of Health that is able to employ specialists and consultants in public health and to deploy them to work with other organisations-whether local authorities, consortia or whoever-to use specialist skills appropriately and effectively, and able to put surge capacity in place to deal with emergencies and things if it needs to do so. We think that that could work very well.
We acknowledge the issue that of course local authorities will want to feel the people working for them are their people working on their behalf and not on behalf of Government. However, entirely reasonable models already exist. For example, all university academics are employed by universities, but clinical academics, employed by a university, also work in the NHS and there is no doubt that they are working for their trust when they work in the NHS. We see that model as working very well and we are very positive about it. We do not see working as a directorate of the Department of Health as the right way to go, for the reasons I have explained. I take the point that the Department of Health needs public health expertise. It does, absolutely. There is not nearly enough of that inside the Department of Health at the moment, in our view, but that isn’t the same as the agency that we are talking about.
Finally, on accountabilities, that model, we feel, will work only if the local authority is clearly in charge all the time and not if sometimes it is Public Health England and sometimes it is not. The local authority is in charge, with Public Health England supporting local authorities to discharge their very important responsibilities for health improvement and protection.
Q7 Valerie Vaz: Before I hear the others’ view on that, who, in your models, would have control over the population view if you remove it down to local authorities? They are only interested in their particular area, so who would pull together all that evidence? Who is doing it now and who will do that in the future under both your models?
Professor Hunter: The local authority would be concerned about its population and its community. It would have a population perspective.
Q8 Valerie Vaz: Would the GP have that?
Professor Hunter: GPs are variable in whether they see a population as opposed to individual patients. I think it is very much the latter. There are exceptions, but generally there is a problem in general practice and given the reality of mixed boundaries-lack of coterminosity-between GP consortia or whatever takes their place and the local authority, there would be a tension there.
Nationally, at the moment, the top health person is the Chief Medical Officer, and they ostensibly have responsibility for public health in the round in government, not just in the Department of Health. I think we are wrong if we see public health as only being the responsibility of the Department of Health. That has been a weakness in the past. Arguably, in most Governments, Departments of Health aren’t seen to be necessarily the strongest Department. If you think about what happened under the previous Government, it was the Treasury that drove much of the impetus on public health, not the Department of Health. It goes back to Lindsey’s point about the weakness in the public health group, if you like, in terms of the capacity to make public health matter in the Department of Health. The trouble is there are no rights and wrongs or perfect institutional structures here. There are weaknesses and strengths in all these models and there is no single answer. It depends on what you are seeking to achieve .
There is a worry with nextstep agencies. For example, NICE is a special health authority that has never seen its role as being to antagonise or take on Government, much as it would like to on occasion. Some of its guidance has begun to challenge what the Government is doing, as occurred in its public health guidance that came out last summer in respect of alcohol misuse and cardiovascular disease prevention-the Government resoundingly dismissed it. There were issues there affecting the whole of Government and the Government said, "We’re not interested in all this. Your role is to influence what has happened locally." NICE withdrew at that point and didn’t confront the Government, so I’m not sure being independent, in reality, makes a great deal of difference.
Q9 Valerie Vaz: I want to come on to NICE, but could I hear from Dr Sim?
Dr Sim: Our view about Public Health England is very much in accord with what you have heard from Professor Davies. I don’t want to take time, but I would simply say that we have very similar views about the need for Public Health England not to be part of the Department of Health-for very similar reasons.
If I may, I will say something more about local accountability because Professor Hunter mentioned dual accountability to the chief executive in local government and to Public Health England. The reality we are picking up from colleagues is that accountability at a local level within local government is not necessarily to the chief executive. If you look back-at what some people are calling "the golden era" and what others are calling "the era well left behind"- the medical officer of health was a very senior officer within local government and had the sort of freedom of speech to which Professor Davies is alluding. If you are a third-tier officer accountable to a director of adult social care, that is somewhat less likely, I feel, and there is significant concern about whether the public health voice would be heard, let alone heeded, in local government if it is that well hidden. That is a real concern among our public health colleagues.
Q10 Chair: Factually, is that where it is now envisaged the local government responsibility will rest as part of adult social care?
Dr Sim: No. Factually, it is an incredibly variable feast, so there are some directors of public health who are negotiating and have already been offered posts that are directly accountable to their chief executive in local government and-
Q11 Chair: But it rather undermines the whole logic of taking public health out of the health service on the grounds that it is a crossgovernment responsibility. If you take it out of the health service and put it into social services, it’s a step backwards, isn’t it?
Dr Sim: There are certainly examples of that, which is why I am suggesting it is possibly inappropriate. It would be very helpful to protect that role in terms of its breadth within the organisation, which is not the case at the moment.
I was going to respond about general practice very briefly. I work part time as a salaried GP-I should declare an interest, perhaps-as well as being a public health specialist. My GP colleagues, as somebody said, are very variable. It is very common for GPs to recognise and to be aware of the importance of public health. The average GP, or most GPs, are not trained in public health. Their experience, largely, is of delivery and of secondary and tertiary prevention, and they recognise that, particularly with the encouragement of the Quality and Outcomes framework. Those are the main issues around the public health agenda that I think GP colleagues are interested in and have experience of. They recognise that they need public health specialist expertise and-I do not know if this is an upcoming question or whether I should pick it up now-there is a lot of concern about what that might look like, how they would access it, whether consortia can afford to buy in public health expertise, whether local authority public health departments, if they exist in that form, will be allowed, encouraged or released to provide support to consortia, and whether, as is one of the concerns, there will be an isolated very parttime presence in a consortium that would be its public health presence. In an isolated, very parttime, no team support presence, it is very difficult to be effective.
Many consortia we are welcoming are looking at having a director of public health on the consortium board which, obviously, is very helpful and could well provide a public health conscience for that organisation. However, they will need to call upon the proper resources of public health expertise if they are going to be seriously influential, in the work of the consortium, for the consortium to commission on an evidence base efficiently, effectively and to meet the needs of its population. In our view, they need proper public health expert advice and support to be able to deliver on that agenda.
Angela Mawle: To answer generally, while we were very excited when the public health White Paper came out because it gave a vision, we thought that the crossdepartmental SubCommittee of the Cabinet headed by the Secretary of State gave a too general acrosstheboard look. We feel in the meantime that, as to the kind of processes-I will not say factionalisation-there has been a degree of divide and rule that means that people are running for cover and are more worried about posts and positions than about this vision. The actual time taken to achieve this has been far too short and the vision has been lost in the process.
Michael Marmot came out at much the same time and we thought, "Great, the local authorities can take over." If that was implemented, we would have wonderful public health. Throughout the life of the UKPHA-and I am sure that David will support this-we have been trying to take apart the medical model of public health. Because it is in the NHS, it is very easy to see public health as an NHS function. The public are brought into this, too, so they tend to see health as something provided by doctors, nurses or the clinics-and I am sure the GPs will agree with that-but they don’t see themselves as coproducers.
I and the UKPHA see GPs as prime champions in the community alongside the director of public health. However, the problem arises if there is a cultural difference between the two organisations-local authorities and PCTs. There is a huge cultural difference in terms of training processes, and the kind of member involvement that you get in local authorities you certainly don’t get in PCTs. Therefore, the whole opening up of people to looking at new ways of doing things is very hard for them, particularly when the pace of change is so fast.
When I first came into this post, Wanless was pronouncing the £30 billion saved to the NHS. He said that most people in public health do not have "health" in their title and that public health is everybody’s business. Donald Acheson talked about the organised efforts of society. We don’t want to see lost this opportunity to have champions out there with communities helping people to produce their own health and to understand their role-not to be asked or told how to do it. I am sure that that is not what people want to do, but it is a culture that has built up through the generations and is particularly reinforced by the fact that, since 1974, the public health provision has been in the NHS.
We see accountability as a real issue because, clearly, if the current directors of public health are going to be reporting to social services or somebody similar, that, to them, immediately takes away their credibility, their independent voice, etc. Perhaps if there was a bit more time, but we haven’t got a pause in ours. I know the pause of the Bill is happening and we have used that very creatively, we hope, to encourage an involvement of everybody in the thinking of how you can create these champions who will implement and help to develop the Marmot work out there in communities, which is where GPs are active and where all health professionals are active.
In the northwest, where we are working on fuel poverty actively at the front line and not just sounding off about it-when you get into these sorts of issues it is easy to sound off about things and not be involved in the practicalities-we found that when you approach GPs, PCTs and local authorities in a collaborative way you can get a very good linking and crosssectoral approach to public health problems, notably fuel poverty. That really helps to free up both energy within the work force and data release in a way that does not impact on the Data Protection Act. If you want to do this, you can. However, because we don’t have a "can do" culture and because of the speed of these reforms, it stops this vision so that even people in our organisation-who are very keen to see this work and want to see local authorities take authority for public health and well-being-are really worried about the division that is being created by the speed of change and the inability to look at the individual people currently involved in delivering that.
One more thing is that in the future we should use a vision-and I would love everybody to be able to help in this-to see what public health would look like in 10 or 15 years’ time when we are confronted with all the issues about climate change, environmental degradation, population and food production. What will it look like then and what do we need to do now to prepare for that? With this constant navelgazing in looking at this current issue, we are losing sight of what should always be, for public health, a scanning of the future and what is going to be fit for purpose. I would endorse what has been said but I have to say, for our membership, that we welcome the vision, the crossdepartmental approach and the fact that Marmot has been put into that report. We want the opportunity to help it all work.
Q12 Chair: What is your answer to the question that Professor Hunter raised at the beginning about accountability in the proposed structure of the director of public health? Is it to the local authority or is it to Public Health England-or should it be-and how is that balance struck?
Angela Mawle: I have controversial views on this and I haven’t discussed it with people here. My view, and the view of a large number of our members, is that the local authority has always-or for a long time now-had statutory responsibility for health and well-being. That should remain with them. Somebody in the local authority has to be responsible for the health of the population and that should be at the highest level. We argued a long time ago that there should be a cabinet post for public health. We are saying there should be a cabinet post for public health and it should be at a very high level-whether it is chief executive or whatever, there should be somebody there-whether you then buy in services from Public Health England for specialisms, or whether you spend time bringing your own work force up to speed so they begin to take the responsibility for health.
Michael Lyons, when he was doing his report on the council tax, was astonished-he reported to one of our seminars, didn’t he, David?-and could not believe that when he talked about public health, that local authorities said, "Gosh, no. That’s the PCT. That’s not us," and he felt that was because they didn’t have the confidence to say that they were health because health is the NHS, not them. That is why I think this is a real opportunity. I am not saying, in the current position, that I could say which would be the best position to be in but, looking to the future, I would definitely see local governance, local collaboration and community involvement and that the person responsible for health is at the very senior level of all the collaborations at local authority level which help create a healthy community.
Professor Davies: Can I pick up a number of those points, particularly focusing, first, on the director of public health and their accountabilities? We are saying that the local authority should be clearly accountable for improving and protecting the health of its population. They need somebody who understands how to do that, and who can do the business, put in a position to be able to do that for them and to lead them and enable them to do it. That we see as the director of public health. Of course they have to be senior in the organisation and of course they have to be accountable directly to the chief executive of that organisation and with direct access to councillors. If they do not have that, they will find it enormously difficult to influence across the whole breadth of the local authority and really to realise the potential that that brings with it.
I mentioned that they need to be qualified, but the Bill just says "Appoint an individual". I have heard it mooted that, in these stringent times, a local authority may decide to add these to the responsibilities of a director of social services or even the director of education. I would love to think that a director of education was qualified in public health-that would be fantastic and I could see great potential in that-but we really do have to have in the Bill that this person needs to be qualified and we can perhaps touch later on other aspects of regulation.
The directors of public health themselves, I think, need to be able to influence and provide this leadership across all three domains of public health. The health services-making sure you have the right health services when you want them-health protection and protection against harm, and health improvement and healthy lifestyles, if you like, work together. The DPH and their team are the people who can look across all that and advise on balance generally. As individual members of the public, that is what we need.
Professor Hunter: Very quickly, we should not forget that leadership in local authorities comes from elected members, not from officers. Therefore, the role of a DPH moving into local government will be very different from the role they may have enjoyed in the NHS because-and local government will tell you this-using the word "leadership" to describe an officer function is incorrect . It is the officers who support the leadership coming from the elected member. A quite different culture and set of skills are needed for that relationship to work. That might account for some of the protectionism and tribalism we are seeing in relation to fears in some public health quarters about going into local government because-
Q13 Chair: I think you mean that the shrewd officer of local government volunteers that his councillors are the leaders.
Professor Hunter: Of course. It is the "servant leader", or whatever term you might use, but it is not an up-front leadership role. It is a very different kind of leadership role from that which exists in the NHS. Don’t forget that this agenda is all about localism. Local authorities are different. That is the whole point about local government. They will vary in how they want to hold their DPH to account, but that is the price of localism. You are either for it or against it, but if you buy it, you have to buy what goes with it, which is variation and difference.
Q14 David Tredinnick: Listening to you all, it seems there are a couple of big issues here. You suggest first that local government doesn’t have a lot of confidence in becoming responsible for health because it has not done it for so long-since 1974-and, secondly, that if they are to make anything of it, they are going to need expert advice, although I am not sure you see where that is coming from. Is that right?
Professor Hunter: Some local authorities have a very confident view about their role. Birmingham, for example , appointed their own DPH alongside the DPHs from the primary care trusts. There are different models and some local authorities do see their role very much as being about health and well-being. They use the term "well-being" rather than "public health" to describe that, but they would see themselves as being at the forefront of health improvement and of having more employees in public health than the health service, if you take environmental health officers into account, for example.
Q15 David Tredinnick: That is a huge authority you have cited.
Professor Hunter: It is, yes. I am using one extreme.
Q16 David Tredinnick: Is that representative?
Professor Hunter: I don’t think any local authority is terribly representative-that is part of the problem. But I don’t think it is fair to say local government-
Angela Mawle: It shows what is possible.
Professor Hunter: It is what is possible but I think local authorities, generally, are up for this. Their worry-the poisoned chalice bit of this-is that they are doing it at a time when they are being massively cut and having to retrench and make savings in all areas that, arguably, contribute to public health. Their worry is that they are taking on this exciting and demanding role at a time when they are being decimated in some respects.
Q17 Chair: In a nutshell, I don’t think we are hearing from the panel of witnesses a case against a strong local government leadership role of this public health function. It is a question of how that relates to the rest of the system.
Angela Mawle: Absolutely.
Professor Hunter: Yes.
Chair: I think that is a fair summary of the starting point.
Q18 Chris Skidmore: Can I, very quickly, pick up on that? I don’t know if you have read an article that was published in The Lancet back in February: "Public health in England: an option for the way forward?" You all seem to be in broad agreement about local authorities having a greater role and, as far as I am aware, this article mentioned that the big issue with moving public health into local authority control would be a lack of scrutiny and that "Moving local public health functions outside the NHS risks them being overlooked to a much greater extent than when they were within the NHS, and-crucially-local government is not gaining any of the additional regulatory powers it would need to address the determinants of population health." Is that a valid risk?
Professor Hunter: I don’t think so. As Angela said, local government has had this power since 2000 for the health and well-being of their communities. We overrate the extent to which public health has been successful within the NHS, to be honest. I’m not sure the evidence base is there to substantiate that. Many of us feel disappointed with public health punching below its weight, in some respects, over the last 30-odd years and the distraction by an NHS agenda has been very powerful. We have seen examples in the past, and the previous Chief Medical Officer, Liam Donaldson, used to complain about public health budgets being raided by primary care trusts to prop up hospital services. There are huge tensions. Going into local government could be a relief and a release from all of that distraction from the core business in public health, which is why I think the three domains are problematic. The third domain, health service development, is not one that should necessarily sit with the DPH moving into local government. You could decouple that function and put it back into the NHS. I accept there’s a public health role in the NHS, but as to whether you need those three domains being overseen by one person is arguable. Apart from being a massive job stretch, it has been a problem in the past.
Q19 Valerie Vaz: When you say "put it back in the NHS," whereabouts do you mean? Do you mean Public Health England or-
Professor Hunter: It depends on what we end up with, but the commissioning bodies, and/or health and well-being boards, if they continue to exist, and foundation trusts. There are many foundation trusts which are seeing their role in terms of easing demand on the NHS and of therefore being about having to take an upstream public health perspective both with staff and patients.
Q20 Valerie Vaz: It is quite important, isn’t it, health care public health?
Professor Hunter: Absolutely.
Q21 Valerie Vaz: People seem to be forgetting about that.
Professor Hunter: Because it gets lost in the White Paper. It is not really made enough of.
Q22 Chair: Is it not a core function of commissioning?
Professor Hunter: Yes.
Q23 Chair: I am slightly surprised you put it into a foundation trust. I would have thought health care public health.
Professor Hunter: It is both.
Q24 Chair: If commissioners aren’t using health care public health as one of their signposts, I don’t quite know what map they are using.
Professor Hunter: No, absolutely. The joint strategic needs assessment has to be at the core of that.
Professor Davies: At the core of the joint strategic needs assessment is the DPH’s annual report, which needs to be on not just the health of the population, but the needs of the population and the extent to which those are being met across health services and on health and social care and everything else.
Q25 Chair: Do you agree with what Professor Hunter was saying about the possibility of splitting the health care public health function away from the rest of public health?
Professor Davies: It is a difficult issue. The director of public health needs to have that responsibility to advise across all of it. How the public health expertise in a community-and I am including in that everything that is supporting that community, including what is employed by Public Health England or wherever-is, on a daytoday basis, organised to best effect is difficult to get right. It is absolutely right that consortia and any commissioning body need to have public health expertise embedded in their fabric. On the other hand, having one person doing it half a day a week, completely isolated from anything else that is going on and not understanding the other bits of public health in their community, would be equally poor. We have to find a way of bringing that together. That is why we are saying that having a director of public health with those teams of people acting on their behalf and outposted for part of their time makes a lot of sense. Picking up odd bits of public health time does not. I think that foundation trusts should have public health expertise in them because they have huge responsibilities, and public health in health services is about making sure that services are efficient, effective, appropriate and accessible. If foundation trusts aren’t doing that, I don’t know what they are doing. They need to have that expertise.
Dr Sim: Can I come in there? I, too, would feel very uncomfortable about fragmenting the public health function even more than is likely to be the case. I have the pure good fortune to work in an area where the proposed consortium, the unitary authority and public health could all cover the same ground. There is every reason, in that situation, to have a director of public health holding the ring on behalf of the health of the population, influencing local government and commissioning and, at the same time, if resources allow, influencing the thinking in the local foundation trusts, and local mental health trusts for that matter.
There are two big issues. One is to have the leadership and the resources available to deliver on improved health on behalf of the population. The other is that coterminosity isn’t particularly common in terms of the proposals for consortia, and is further complicated by the lack of any geographical boundaries. I am now talking about coterminosity on the basis that it is a town with reasonably circumscribed edges to it, but it is not purely coterminous. If a consortium is responsible for only its registered patients, that is an added complication and obviously has significant implications for health inequalities, if we have an unregistered population that is left out in the cold. But I don’t think that is what we are talking about now.
Q26 Dr Wollaston: It would be interesting to hear your views about coterminosity and how that could perhaps be changed in the Bill. However, I want to focus on the point about good information for consortia because concerns have been raised about the future of the work of regional public health observatories due to the core cuts of the Department of Health funding. Could you explain the role that they play in the public health system, whether there are grounds to be concerned and what the way forward is?
Dr Sim: Yes. The public health observatories, at the moment, are regionally based and there are 10 in England. They are providers of, to my mind, an extremely robust quantity and quality of information about health and health care, health services and the health status of the population at regional level. For many health topics, the observatories have also provided information and are able to do so at a much more local level. Therefore, yes, they have immense value at a local level. Some of the examples one might take are in terms of their value to primary care commissioning around some long-term conditions where they have done a lot of work, they have a nationally organised association and each of the observatories takes a lead role in certain areas. For instance, around the care of people with diabetes, the observatories have produced information for the whole country at a very local level, which is immensely valuable for commissioning to make needsbased decisions or to allow needsbased decisions to be made about, for instance, the planning of services, planning for primary and secondary prevention and the needs for health care. I am picking up that example as a very common condition with a fair degree of potential for prevention and a lot of potential for high-quality, needsbased commissioning.
What I would say-and my colleagues may not agree-is that I have a very high regard for the information provided by the observatories and I think it is wonderful. But it helps a good deal if, at a local level, you have people who can interpret that information and who know what they can do with it. You still need the local public health expertise-I feel as though I am making a claim for this, as I believe it to be the case-to make really good use of that information, to interpret, analyse and then to advise local commissioners, the local authority and local health care trusts, how best to promote the health of their population by using that information. It will be a great loss if they go.
Q27 Dr Wollaston: You feel they do play a valuable role in advising those local public health specialists.
Dr Sim: Very much so.
Professor Hunter: Yes.
Professor Davies: I have a couple of facts. The funding for the Association of Public Health Observatories, which is the co-ordinating function that Fiona was describing, is not there any more, so there is no Association of Public Health Observatories to any good effect at the moment. One of their strengths was that they were well coordinated-they had this local ability to influence and give information-and one would take a lead on one thing and another. That is much more difficult now, in their current circumstances, although they are trying their best to do it. They also have a 30% cut in their core funding for 201112, which is a cut of £1.5 million in terms of resources going to public health observatories, as I understand it, in this coming year. That, of course, is causing them huge uncertainty. Put that alongside the fact that a couple of them are based in universities, and at one of them in London the staff have already been told that they are at risk of redundancy, if we are not careful, we will end up with a great fragmentation and dissolution of the expertise that is currently really working in a very wellcoordinated way.
Q28 Dr Wollaston: To clarify, you are saying they have a 30% cut this year and then no funding for subsequent years.
Professor Davies: The Association of Public Health Observatories has lost all its funding. It was funded for £300,000 over three years and that has now ceased. The core funding for the observatories themselves has gone down by 30% for 2011.
Q29 Chair: How are they currently funded? Is it a direct grant from the Department? Does it come out of the university budget?
Professor Davies: Direct.
Professor Hunter: Direct grant from the centre.
Q30 Chair: So it is a direct grant.
Professor Davies: From the Department of Health.
Dr Sim: It is a direct grant but each of the observatories has also been entrepreneurial in terms of its local or regionwide contracts-with both NHS and other bodies.
Professor Hunter: The North East Public Health Observatory, with which I’m most familiar, set up the National Library for Health which is now part of NHS Evidence, which NICE runs, but the contract is with NEPHO-the North East Public Health Observatory. Also, the Learning Disability Observatory is housed there, so NEPHO has been entrepreneurial and there have been all sorts of spinoffs into other areas.
Another thing to mention is that having NEPHO located in an academic setting has been useful because it feeds into training and research in a way that wouldn’t otherwise be the case if you didn’t have that resource or relationship. There are huge databases held by NEPHO that provide a rich resource for students and others to access and use in their teaching and research. It is a valuable spinoff which, again, we lose at our peril, I think.
Q31 Chair: Are there any opportunities for those observatories to generate alternative revenues by using some of those resources you have referred to, either from within the health care system or beyond it?
Professor Hunter: They are looking at that and many of them are exploring the social enterprise option, possibly turning themselves into a different kind of body. The view is that you need some element of core funding to enable you to do that. You need the seed corn funding-the pump priming-to enable you then to go and get other funding. Many of the PHOs have used their core funding, which is roughly £250,000 per annum, to do that. You do need that continuation of the core element to generate new income to do additional things.
Professor Davies: But they need to be employed in the future or organised in a way which allows them to do that, which, if they were part of a directorate of the Department of Health, they couldn’t.
Q32 David Tredinnick: As things stand at the moment, how do you see the role that the observatories currently play being carried out in the future?
Professor Davies: We would love to see that there are still to be observatories that retain some sort of subnational-more close to local-context so that they really can understand the bones of the communities they are providing the information for as well as doing the hardnosed statistical analysis and data collection they need to do, and they can set their information in context. We think that that is very important. But we would like to see a network of them. We want to see them sharing resources a lot better. We see Public Health England as a good place for that. I don’t see any reason why an organisation that is funded and managed by Public Health England couldn’t be nested in a university in much the way they are at the moment. As long as it is a coherent set of functions with good relationships locally, that is how we would see it. We do see Public Health England as having an important co-ordinating role to ensure that that happens.
Q33 Grahame M. Morris: In relation to that, the Bill is proposing huge changes to the architecture of the NHS and a new role for the Secretary of State in relation to public health. For me, it is a huge priority. Professor Hunter mentioned the North East Public Health Observatory and the key role it plays in relation to addressing issues associated with barriers to people with mental health accessing health services. That has national significance, hasn’t it, even though the work is carried out in the northeast?
Professor Hunter: Absolutely.
Q34 Grahame M. Morris: I went along to listen to Angela and Professor Sir Michael Marmot last week talking about the impact of cold homes on public health. It was an excellent report with national significance. I wonder where it should sit in order to secure this very important service, the evidence base of which is vital to proper public health policy. Is there not an argument for making a special health authority? Would you support that view?
Professor Hunter: It is easy to have a little-
Q35 Grahame M. Morris: I am not leading you. I was seeking an opinion in terms of the Faculty of Public Health and the Department.
Professor Hunter: Personally, I would like to see much more of a tieup between the public health observatories and what NICE does, in terms of both generating and implementing the evidence. At the moment NICE has an implementation team, but it is only seven people, one in each region. We have one for the north, which is everything north of Doncaster, I think, up to the borders. That is a problem because they do valuable work but it is not enough capacity. It seems to me you have all this resource in the public health observatories, which, in a sense, has been wonderful, but you could argue that there is a winwin to be got by linking some of these activities together in a different way to maximise their potential. These analytical skills are scarce-they are not plentiful-and we do risk losing them. Certainly, with our observatory in the northeast, we have lost staff. Staff sensed uncertainty and disappeared-they have gone. Some went to academic posts and some went outside the university, so we are losing the capacity built up over many years already. It seems to me that we do need to think about the options. A special health authority would be one option, but we should also perhaps be thinking about ways in which we could more creatively make better use of the information and analytical resources we have across NICE, PHOs and elsewhere.
Professor Davies: My support for them being part of Public Health England is dependent on Public Health England being constructed as a special health authority or an Executive agency.
Professor Hunter: Yes, being an SHA.
Grahame M. Morris: Okay, I understand.
Chair: We can’t spend all morning on observatories. We will turn to questions about nudge.
Q36 Dr Wollaston: Touching on nudge, the Government have effectively said that the public health White Paper, "Healthy lives, healthy people" constitutes its response to the review led by Professor Michael Marmot. How adequate a response is it?
Professor Hunter: Underwhelming, I think. On the first page of the White Paper it talks about this being a response to Marmot, but then the rest of the White Paper is about individual lifestyle behaviour change and that is not really what Marmot was saying in his six areas of policy priorities, all of which seem to be about tackling the upstream social determinants of health. There is a role for lifestyle and behaviour change in the mix, but to see that as a centrepiece of changing people’s lifestyles flies in the face of the evidence. The evidence doesn’t exist to back that up. What evidence there is, which is reasonably positive, says that it will take 10, 20 or 30 years to bring this about, and even then there is no guarantee it will be sustainable. Given that we do not have that amount of time, given the pressures on the NHS budget from lifestyle diseases-obesity, alcohol and so on, which are complex and immense and with which we struggle to cope now-to see this as an issue for individual lifestyle and behaviour change is completely missing the point. Therefore, I am disturbed at the shift from being a nanny to being a nudger. There is a lot to be said for Government shoving people occasionally. The public health tobacco ban was a good example of that. It didn’t go against public opinion-it largely went with the grain of public opinion-and it has worked. There is a role for upstream Government action. To see it all as being about nudge and incentivising individuals is not the right response.
Q37 Dr Wollaston: Evidence for shove but no evidence base for nudge.
Professor Hunter: That would be the conclusion of the Cambridge research unit set up to look at nudge, and the BMJ article earlier this year concluded that, as of now, the evidence base does not exist.
Q38 Chair: There were two elements of your reply. One was that you feel-if I am hearing you correctly-that there is too much emphasis on the local and not enough on the national, while the second is that there is too much emphasis on the nudge and not enough on the shove.
Professor Hunter: Nudge can be at national and local level. It depends what you mean by "nudge", to be honest. It is a very flaky, slippery term.
Q39 Chair: What do you mean by it?
Professor Hunter: I think what is meant is incentivising people to behave differently by, maybe, bribing them, as they have done in Dundee. They have given teenage pregnant mothers vouchers to shop at M&S if they stop smoking-that kind of thing-which has worked. But there is an ethical argument as to whether you should be bribing people to behave sensibly and how long you keep the bribery going. Presumably, it is for the extent of the pregnancy-whether that then encourages multiple births, I’m not sure. There is an issue about that kind of behavioural response-whether it is both ethically and practically the right solution.
Professor Davies: We were encouraged to see in the public health White Paper the Nuffield interventions ladder, which does acknowledge that there is a whole range of interventions needed. For any public health programme to get populationbased change, you need to bring all those things into play. Regulation has a place and so does, from time to time, giving people a bit of help to move in the right direction. To put a huge emphasis on nudging, for which, as we have heard, there isn’t evidence, and to say, "We will do regulation only if nudge doesn’t work," is not an evidencebased way of going on. There is evidence that regulation, in the right place, when the public are with it, can have an enormous effect and bring about a real step change. We have seen that with seatbelts, drink-driving and tobacco, as we have heard. That would be our position. Everything has a place, but we think you shouldn’t simply wait for the lower levels of the ladder to fall off before you put the top one there.
Angela Mawle: My concern is that it can be manipulative. One of the examples I heard from a learned seminar was when they put a bus stop outside a dementia care home. The reason they put the bus stop there was because people would wander and off and go and find a bus to catch, and they thought that putting the bus stop there would encourage them to wait outside the care home. Ethically, that is very iffy, and if you subscribe to that kind of individual way of going on, as our colleagues have said, you are ignoring the bigger picture. You mentioned-I am sorry, should I call you "honourable gentleman"?
Chair: None of us do.
Grahame M. Morris: That’s the nicest thing anyone has said to me.
Angela Mawle: I am a bit nervous of this setting.
You were referring to last week’s launch and that showed that housing costs for the NHS are £2 billion and they are £1.8 billion for the police service-because of dangerous housing and also distractive, delinquent behaviour. Why does the White Paper talk about Marmot and say, "Yes, Marmot is great"-and he was there supporting that argument? The housing costs to health are huge. Of course, it takes me back to my previous statement, about Wanless about prevention-and prevention has always been Cinderella. Public health is prevention and we have never included "public" in public health, as far as I am concerned. We have hardly mentioned at all this morning the people out there who could make it all happen. Nudge is something that you can use-I don’t like the term "armoury"-in a range of ways to help people improve their life, but you have to address the causes of the causes, and you can’t quote Marmot if you are not then prepared to take on the implications of what he says.
Dr Sim: I agree that the evidence for nudge is very limited. What there is suggests that the people who are going to be influenced by nudge are largely those who are already on track for making a behaviour change, rather than those people who are much harder to reach. If it is effective at all, we are talking potentially of widening health inequalities. Certainly we feel-particularly if the public is beginning to realise that certain things are in their interests-that the Government should not shy away from regulation to influence them.
Chair: This huge subject is probably not at the heart of our inquiry, but it is clearly relevant. David, you were going to ask about the role of the Secretary of State.
Q40 David Tredinnick: Yes, indeed.
How would the Secretary of State’s role in respect of public health change under the Government’s proposals? That is my opening question.
Professor Hunter: The honest answer is that I don’t think we know. First of all, it presupposes the Secretary of State will be able to divest himself of the NHS in the manner that is proposed. I am not sure, in reality, that that will prove quite so easy, despite having the independent Commissioning Board. So I remain to be convinced that a great deal will change in practice. The jury is out on that. In terms of his or her role in respect of the broader health agenda, that is very welcome, potentially. In the past, those of us looking in from the outside have been critical of the Department of Health for not being a health department at all, but rather of being an illhealth or a sickness department and not taking public health seriously. If it changes its philosophy, ethos and culture so that it is more health-focused in the broader sense that we have been talking about, that is to be welcomed, but I am not quite sure what the drivers would be for that. At the moment, you have the Cabinet SubCommittee, I think, which the Secretary of State chairs.
Q41 David Tredinnick: Yes, it is the Cabinet SubCommittee on Public Health. What potential is there for a crossdepartmental approach?
Professor Hunter: There is tremendous potential. But we have been here many times before and previous incarnations of these crosscutting committees don’t seem to have had a great deal of traction or impact. Therefore, one worries that it is simply reinventing the wheel and that the same lethargy or systemic failure will result. Personally, I would be inclined to give that committee chair to someone who is not from the Health Department. If public health is a serious function across Government, it shouldn’t simply be in the silo of the Department of Health or the Secretary of State for Health.
Angela Mawle: I think the Secretary of State should be the champion of public health. I was really impressed by the mental health strategy, about which I spoke to the Secretary of State when it was launched. Clearly, there is an understanding of the breadth of health and well-being, so to have somebody at the head of health who understands that and tries to champion it is really important. As to the actual SubCommittee, I don’t know whether I would agree with David or not because, unfortunately, people still see, as we have talked about earlier, health as being the NHS domain. We called a long time ago to have somebody who is the head of health chairing that committee and enforcing it. We also called for there to be a chief civil servant and a Minister in each Department responsible for health so that that person then reported to whoever was going to be head of that-in this case it is the Secretary of State-to make things happen. My experience-and all of our experience, I am sure-has been that crossdepartmental working is a nightmare because there is no common culture and understanding, and things get reinvented in different Departments. We desperately need to unify and show the public that it is all about being joined up: their transport, their planning, their green space and their housing. Exemplifying that is a brave step to take, and I just hope it happens.
Q42 David Tredinnick: Two different Departments; a department of sickness, too, rather than health.
Angela Mawle: Definitely, beyond a doubt, yes.
Q43 Chair: Can I bring in Professor Davies? I have to say I am a bit of a sceptic about this. It seems to me that what the Secretary of State is envisaged as being in this world is an authoritative voice on some quite sensitive issues of public health. For example, do you think the Secretary of State would have been an effective voice on the MMR vaccine to give people advice about that kind of health prevention, or would it have been better for it to have been from an authoritative voice one step removed from a practising politician?
Angela Mawle: It has to be a relationship. We talked about local authorities and elected members, and the relationship there. There has to be a more mature relationship whereby the political lead is seen as leadership for the whole community and they are informed by expertise. That needs to happen in a partnership-a collaborative approach rather than with these demarcations that occur between civil servants and elected Members. I understand why that happens, but the public don’t trust the system as it currently operates. I see what you are saying-that he or she shouldn’t pontificate on issues about which they are not expert-but if they draw from expertise and then they are shown to have the community and the national population’s interests at heart, I believe it could work.
Professor Davies: I have two points. First, picking that one up, it is fundamentally important that Ministers have confidence in the civil servants working for them and supporting them, and that they do have working for them civil servants who can advise them from a professional understanding on the various other bits of external and independent advice they are getting. They need the Chief Medical Officer, and the Chief Medical Officer needs to be supported by people who know what is what. Ministers need to be confident about that advice. The public need to be confident that there is independent advice that is able to inform them, as I said earlier, from a professional and scientific expert point of view. There are those two different sorts of confidence we need in the system.
My earlier point was going to be about health protection. We have talked an awful lot about lifestyles and a bit about health services. We have not really talked about the emergency response and protecting people. That is where there are some quite important new powers for the Secretary of State in the Bill. For example, he or she will, in an emergency, will be able to direct NHS organisations to do things, to stop doing things and to cooperate-to work together. That is going to be terribly important. Unfortunately, what the Bill does not do is say that they can direct providers of NHS services to cooperate. It says he can stop and start things, but they don’t have to cooperate. In an emergency situation, given the proposed plans for the NHS and for health generally, where you will potentially have a much more fragmented system than you do at the moment, it is very important that the Secretary of State, or somebody, is able to tell people what to do in terms of health service providers. That is going to be a really important new power; I would almost like to see it extended rather than reduced. On the other hand, if you build other controls into the system so that it is not so fragmented, perhaps those powers are not quite so important.
Q44 Chair: I quoted the example of MMR in order to depersonalise this but to remind you of my own experience-trying to be a public health Minister-in giving people assurance about CJD. The result of that, rightly or wrongly, was that the successor Government concluded that this advice was better given by an independent authority, and I don’t find anybody arguing for going back to the old system on food standards.
Professor Davies: I totally and absolutely agree with that. It is that sense of history: the Health Protection Agency was set up for exactly the same purpose. It seems to me that if you do what is proposed at the moment-put the Health Protection Agency, the National Treatment Agency and others into the Department of Health-you will soon find yourself inventing a new organisation to give independent advice, and that doesn’t seem a frightfully sensible way to go forward.
Q45 Chris Skidmore: I have a couple of questions around local authorities. They have mainly been answered, but looking at the nuts and bolts of how they work, first, local authorities’ performance has to be judged against a public health outcomes framework, which is in the process of being developed at the moment. What would you hope is put in that framework and how would you see it operating? We have talked about interventions and budgets and all that sort of stuff and whether that is part of it. Would that be acceptable? This framework can be effective only if it has teeth with which to hold local authorities to account. Do you have any experience yourselves or any research that might suggest how this might come about?
Professor Hunter: Personally, I think the outcomes framework has to be linked to the quality standards work that NICE has been asked to do for the NHS-150 quality standards over the next five years. It is not clear whether public health is going to be included, but it ought to be. It then ought to underpin the outcomes framework and that ought to be the basis against which local authorities are held to account for delivery. I would like to see the Marmot priorities reflected in those health outcomes. If the Government were serious about responding to Marmot, they would build the six Marmot priorities through the life course into those outcomes from early years interventions right through to old age. To that extent, there are bits there that could come together quite neatly into an outcomes framework, which will cut ice only if it is implemented effectively and people are held to account for delivery. The weakness in the past has been that we have not closed the circle in terms of holding people to account. People should be required to implement NICE guidance.
Q46 Chris Skidmore: How would you hold them to account? At the moment we have this health premium idea that local authorities, by reaching their outcome frameworks, might get extra cash at the end of it. For me, that seems to be misjudged in that it should possibly be the other way round. The money should be given to local authorities that are in more desperate need, but surely you should have a system of penalties rather than an incentivisation. If local authorities don’t reach the targets of their outcomes framework, they should be held to account for that. At what level should that be? By the Secretary of State?
Professor Hunter: Ultimately. The thing is we have done away with a lot of the instruments and vehicles that were designed to bring that about. The Audit Commission and the comprehensive area assessment initiative it introduced last year have been scrapped, so a lot of the levers for holding a local authority to account are going to have to be reinvented or replaced in some way. At the moment, it is not clear what the space between the local authority and the centre is going to be in that regard. Obviously, there is a local accountability dimension to this as well, but clearly there is a lot of uncertainty about the national level at the moment.
Professor Davies: Absolutely. If you look at experience in the NHS, why is it that there hasn’t been as much emphasis on public health in the NHS as we would like to see? Frankly, until you make improving health as important to a chief executive as balancing their books, you are not going to get the kind of change that you want to see in health. We have to find some levers that will enable that to happen, and that is what we are grasping for at the moment. There needs to be a really robust set of outcomes in the framework over the whole lifestyle, but we have to be realistic about that. A lot of public health outcomes-changes in health-take years to implement and need sustained action. Somehow the system has to reward sustained action over years, but encourage people in the short term. There need to be some process indicators in that as well so that we can see what people are doing and how they are doing it, as well as what the outcome is. Much as I love outcomes-of course I do-there have to be both.
Q47 Chris Skidmore: The other nutsandbolts issue I wanted to address was funding. Obviously, the White Paper talks about there being maybe just over £4 billion of funding towards public health. There are two issues. First, I wanted to ask you if you think that is enough. By my calculations, if you are doing a wholearea calculation with 60 million people, that is roughly £67 per person per year. Is that going to be effective to deliver public health interventions that will work? Secondly, there is the issue of that funding being ringfenced. Professor Davies, I saw in your White Paper response that the risk in a ringfenced budget for public health will obviously be that that would be expected to cover all public health interventions. That mirrors what the local government group has said in its paper. It is worried that ringfencing will mean that councils will tend to see ringfenced sums as the total resource available for public health. The two questions I wanted to ask were, first, whether you think that is enough money at £4 billion. We have a situation, with Wanless, where the local demographic need will always increase over the next 30 years. Where can you see that sum rising to? Secondly, is ringfencing a good idea-yes or no?
Professor Davies: Is £4 billion enough? I have no idea. It all depends what you want that £4 billion to do and, at the moment, we have no idea what the boundaries of the budget are going to be. The Faculty of Public Health did a survey a little while ago asking people what they thought was spent on prevention, and-a significant number-thought that at the moment we spend about 25% of the budget on public health. That is interesting; I wish we did. Until we know what the boundaries of that budget are, I do not know if it is enough or not. I am concerned about the risk of it being seen that that is all that anybody has to do for public health, given that the whole point of these changes, I hope, is to get many more people engaged in doing what they can from their own budget’s point of view. The value of ringfencing, on the other hand, will be that if its boundaries and uses are defined and clear, there will hopefully be a bit of protection for public health when things get tough and a lot of other priorities come in. It is a way of maintaining focus on public health but, equally, we have to make sure that it is marketed in the right way and that everybody understands that they still have to do their bit.
Professor Hunter: I agree with that, but I take a slightly different stance on the last issue about ringfencing. It is problematic in local government to give a particular function a ringfenced budget when that is not the norm in local government. When you are bringing public health into local government, it is precisely the wrong time, perhaps, to give it special treatment and special favours in respect of a ringfenced budget. I would prefer it if local government welcomed public health with its budget – akin, perhaps, to bringing your own bottle to the party, where you put it into the general collection-"Here’s my budget. I’m going to put it alongside yours."
Under the previous Government, we had the Total Place initiative, which was about pooling resources across all the agencies in a local area-Michael Bichard of the Institute for Government and others were the architects of that initiative-and the pilots were quite encouraging. I don’t think the experiment ran long enough to demonstrate great successes, but in terms of process factors and people beginning to break down silos and to think about a placebased approach to improving health, having those integrated budgets was quite important. The present Government have held on to that through the notion of communitybased budgets or placebased budgets, so it is not dead, but it seems to me that the ringfencing notion flies in the face of that other driver to integrate budgets and not see them as little silos kept separate and protected.
Angela Mawle: I endorse what David said, and what Lindsey said to some extent. How can you have the public health responsibility across the whole authority and £4 billion across the land? It is a nonsense. If you look at the outcomes framework and all the things like social capacity, cycling and housing-and fuel poverty is in there-how on earth can you deliver on the public health framework with £4 billion? It is a contradiction, because if you are genuinely saying that the local authority is responsible for health right across, all the budgets should be used. Are you saying, therefore, that £4 billion across the country is only going to be for health programmes such as obesity and all the usual stuff such as smoking etc.-and I am not denigrating the usual stuff by any means? If it is only going to get funnelled down those particular programmes, that is a real lost opportunity, unless it is seed corning other activities and the DPH, or whoever, goes and says, "Here is what we want to do together. We can feed this much into it. What are you going to do?" and looks at those outcome indicators in a way which means you can deliver them. What is the point of having them if you are not going to deliver on them in a few years’ time?
Going back to your first question about the indicators, process is really important in terms of an indicator because you need to involve communities in this. Over time, it has been shown how much you can achieve by involving communities in their own areas, in asset mapping rather than needs assessment, and you can get a coproduction of health out there with communities if you look at that new way of doing things. Traditionally-and I have worked in both PCTs and local authorities-I am afraid you do things the way they have always been done, and if you don’t, you basically get knocked on the head. In some authorities it is okay, but if you are working with communities in your own different ways, you have to be given the responsibility and confidence that you can do that, and work with GPs-everybody in that community. The process indicators, I think, are really important. The outcomes framework and the indicator that is being developed shows that £4 billion is almost a distraction.
Dr Sim: I was going to add that I have no idea if the amount is adequate or not, but our view is that, ringfenced or not, it is really important that local authorities take responsibility across the board-across all directorates. One of the important concerns to us is that it gives a message that it is only local authority responsibility if the ringfenced public health budget goes into local government. That, immediately, is quite easy to interpret as "Nobody else has responsibility for public health, so the NHS is off the hook" and so are other sectors, potentially. That would be really unfortunate. Whether the amount going into local government is adequate or not, I have no idea, but the message that says the amount for public health is only going into local government is unfortunate.
To pick up on outcomes, obviously the amount does depend a little on what we are trying to achieve by way of outcomes. Our view is that-and I think it has already been mentioned-they have to be evidence based. A lot of the outcomes suggested in the consultation document were beautiful, aspirational things, but with no evidence base to them. The other thing that would have ownership of outcomes is to have some sort of local discretion. Some health outcomes are going to be much more relevant to certain communities. If you get local ownership with inter-agency contribution to achieving them, they are much more likely to be achieved. There is something about not just having a blanket approach with the "targetitis" that we have seen historically but having outcomes that are meaningful to populations.
Q48 Grahame M. Morris: I have a supplementary question because that is leading nicely to the point I wanted to raise about the risk of fragmentation in relation to the new commissioning arrangements with GPs, especially where there is no coterminosity with the local authority boundary. If public health is the preserve of local government, will GPs commissioning services simply think, "That is not really our concern any longer"? What are your views on that?
Dr Sim: That is a major concern, certainly. I was saying earlier that most GPs view public health as being very important. Increasingly, they are viewing it as something that is relevant to consortia. Precisely what that means is still being bottomed out. I am aware, for example, that the Royal College of GPs is holding seminars around the country to introduce the role of consortia, including their public health role, which is extremely helpful. But we have a long way to go and, unless there is resource to support those aspirations, that is going to be a real problem.
Q49 Grahame M. Morris: I have some real concerns about that. I don’t know if you remember the "Miserable Measures" report that you did for the local authorities with PCT funding. I wonder whether the GPs would recognise the value of such a report. I am sorry, it is just a comment.
Professor Davies: I absolutely agree with all of that and totally share your concern. One way that you could begin to mitigate that risk is if the health and well-being boards, which are proposed as being the places where all the concerns come together, have real teeth and are able to sign off the commissioning plans. If the health and well-being boards make sure that those plans are aligned with the joint strategy and the joint strategic needs assessment, you can then see that you have some way of bringing coherence to the system. However, if the health and well-being boards are simply fairly benevolent talking shops, where are you going to go, really? There is nothing there to encourage and inspire anybody.
Q50 David Tredinnick: What impact will the abolition of the boundaries have on the collection of information and statistics that are relevant to public health?
Professor Davies: It will make it hugely more complex. The best we can hope for is that the abolition of boundaries means that GPs do not have their patients in particularly widespread areas. But there is the potential, particularly with commuting and so on, for them to have patients spread over a huge number of local authorities. That will make things much more complicated, although not impossible, because it means that the analysis and the collection of data will take longer and will need to be much more carefully thought through in terms of the way it is brought together.
Q51 Chair: Nobody has commented specifically on Chris’s question about health premiums and the extent to which incentivising authorities to do things is a sensible approach.
Professor Hunter: I agree with your scepticism. I don’t think they are a good idea. I think they will prove unworkable, particularly for the local authorities that, for whatever reason, do not meet the criteria for the premium through no fault of their own-through circumstances beyond their control. Battering people over the head if they don’t perform, even though their ability to perform is limited by what they are able to do directly, is a rather curious way of trying to incentivise behaviour. I am not sure it is a mechanism that is going to survive, to be honest, or have real impact .
Professor Davies: I cannot see how you could make it work. All I can see is that it will exacerbate health inequalities rather than tend to reduce them.
Professor Hunter: Yes. It will do the opposite.
Professor Davies: It is a totally perverse incentive.
Q52 Valerie Vaz: Kensington and Chelsea would get the most money.
Professor Davies: Yes. That is especially the case in local authorities where you have a lot of what they call churn-as soon as the population starts to be doing better and gets a bit healthier, they move on. How do you measure whether that local authority is really doing good stuff or not? If it does not seem to be making a difference, you will not be giving it extra money-that is not fair.
Q53 Dr Wollaston: Can I go back to an issue that was touched on briefly before: whether GPs tend to focus on the patients who are in front of them in the consulting room rather than the population as a whole, and whether they are even less concerned with those who aren’t registered with them as their GP? Several members of the panel have expressed concerns about the abolition of practice boundaries, particularly with the new funding formula coming in. How fair is it to doubt that GPs will take a public health view when acting as commissioners?
Professor Hunter: How fair?
Q54 Dr Wollaston: Yes. Do you think people are right to be concerned?
Professor Hunter: It is fair to be sceptical. As I said earlier, I am sure there are exceptions. The GP par excellence in this area was probably Dr David ColinThomé who, before coming into the Department of Health to head up primary care, ran a very successful health centre in Runcorn in Cheshire – Castlefields – that put public health at the centre of its activities. It was, in many ways, a mini version of Kaiser Permanente in the United States, in terms of encouraging people to stay well. It is not undo-able here, but it is not part of the general ethos and culture of general practice to behave or operate in those ways. There is either a huge training issue here-a huge development issue-as we have to accept that some GPs will do it and others will need a lot more help and support. I It is high risk.
Q55 Chair: If primary care is to fulfil its part in the refashioning of health care, you cannot accept that they will not do it, can you?
Professor Hunter: No, because primary care is not general practice. We often confuse the two, but if you go back to WHO and Alma-Ata in the 1970s, it is not about general practice. Primary care is much broader.
Angela Mawle: There are some hugely brilliant GPs around. There are the ones we work with up in the north-west and in Bromley-by-Bow. Bromley-by-Bow is unbelievably good. It is a total public health experience, or health and well-being improvement experience, if you go there as a patient, I am sure. Obviously I am not a patient there, but it just shows. If it becomes the ethic or the way we go forward and society points in that direction, more and more GPs will want to join that. Before now, it has all been silo-d-very professionally demarcated out-as to who does what and where. Patients see it like that too, so you don’t get this freeing up of the energy we spoke about earlier, about how you can engage in new and different ways of working. I believe that GPs are very capable of it and, because they have always been traditionally small businesses as well as altruistic doctors, they have been able to forge their own way, take chances and move on. I think that that is what they need to do, and I am sure they will. They should do it and have to do it.
Q56 Dr Wollaston: Do you think there is a risk, though, that where it is happening well already, it will continue to work well, but in the parts of the country where general primary care is, if you like, failing, we will see that inequality widen?
Professor Davies: That is a huge risk. Fiona will know more of the detail. I would say there is middle ground, though. There is a young GP principal known to me up in the north-west who has become really inspired and energised by this and can see all sorts of exciting things to do. She has been in general practice a while and, yes, it is great seeing the patients and everything, but this has given her a new lease of life to get on and do different things and see what they can do together. It has generated a lot of enthusiasm and I am sure that will be great for their patients-and they are going out and getting the advice to do it right. At the other end of the spectrum, Fiona, you might come in here.
Q57 Chair: Before you come in, can I take the discussion a stage further? We can all acknowledge that there is wide variation of experience of general practice and the full scope of primary care. From a policy point of view, how should we go about trying to address those variations of experience? What is the right way of addressing that, rather than simply tolerating the variances you describe?
Angela Mawle: Personally, if we are talking about a new era, with the health and well-being boards, there has to be a raising of awareness. The trouble with the speed at which we are doing everything is there is not the opportunity to encourage people and to give them the hope and vision that Lindsey has described. We need to use the health and well-being boards. We should flag them up as being important. They should be collaborative with communities as well. To become part of them, there should have to be a degree of training or induction, and these classic good examples from around the country should be used. That is resource intensive, but it is a false economy not to do it because, as you rightly said, health inequalities will increase. The ones who genuinely want to do it and can do it will get on with it, and the others will think, "Oh well, they are doing it," and they won’t be audited and they won’t be accredited, in terms of their achievement. I think that, for policy purposes, if somebody could champion those health and well-being boards and say that they must be collaborative across GPs, public health, local authorities and the community, a whole new ethos could be generated. I am not saying it would be, but it is something we should strive towards to overcome that inverse care law, which is what always happens. Whatever anybody does, we end up with the inverse care law, and part of that is because people slavishly follow policy, in that they deliver on their targets and they say, "This is my job now" and they are not given the preparation and development time to help them take on the new agendas. I believe that that is critical.
Professor Hunter: The trouble is that at the moment health and well-being boards have no driveshaft linking them to the consortia. You need to put something in place there or else you do not have them at all which in my view, may be preferable. I share the recommendation in your last report on that-I really do-and having studied partnerships, I can see health and well-being boards being a repetition of what we had in the past, where they are glorified talking shops where people have no power to do anything, and then go back to their host organisations and life goes on unchanged. It is another layer in the system creating significant transaction costs. There are huge risks around health and well-being boards as presently conceived .
Angela Mawle: As presently constituted.
Dr Sim: There is a big difference between what GPs do, what they might do, and what the responsibilities of the consortium are going to be, and I think we are possibly conflating those things. The enthusiastic GPs-the people who are providing wonderful services-are usually providing wonderful clinical services as well as being publichealth orientated. Good general practice, very often, is holistic general practice with a public health-
Q58 Chair: I was asking the question in the way that I did so as not to lead the witnesses. It seems to me that one of the big questions is how we narrow variations in general practice and primary care.
Dr Sim: The role as a consortium then becomes really important. The leadership of the consortium, if it is minded to hold the practitioners to account-we don’t know yet what the clinical governance arrangements are going to be, either within the consortia, for general practice or for the other contractor professions-is potentially important. At the moment the view on the street, if you like-certainly on my street-is that there will be enthusiasts for the commissioning function in the same way as there will be enthusiasts for improving the health of the registered population, as there already is. Some of those enthusiasts will become part of the consortium management and leadership. I don’t know to what extent they will be able to pull with them that rump of perhaps the variation in quality, as you have described it, and pull it up by its bootstraps and to what extent, therefore, that rump could be made accountable to ensure improved practice. It is not only about public health, clearly. It is very much about where the accountability is going to lie, I think, and how that improvement is going to be achieved. Policywise, there is certainly scope to look again at the GP contract in all its parts. Whether that has been considered, I have no idea. I haven’t heard that it is being considered.
Q59 Chair: That is a big subject. Perhaps we will not go too far down there. Did you want to comment?
Professor Davies: Very briefly. I agree that we do need to look at the contract. There is potential there within the contract, but even if that is done, there is still going to be the need for robust, believable, timely information at a practice level because being able to see where your practice compares with others and other people being able to take that oversight is a very powerful lever for change. We have demonstrated, over time, that if we do not have the good information, we are not going to be able to begin to do that.
Chair: It is also one of the things we covered in our second report on commissioning: is it wise to have the commissioning process for primary care separate from the commissioning process for secondary care? We made our view clear.
Q60 Rosie Cooper: I was really taken by what Angela said because in our last report we said that health and well-being boards should disappear-frankly, I am 300% behind that-as they are so constructed. This last weekend I talked to a councillor who is a retired pharmacist, and he was enthused beyond words. He wanted to get on a health and well-being board and change everything, so he was asking me what powers it would have. In my usual style, I said, "A power to spout. You can talk and talk and talk and no one will listen." There is a huge danger here if people start to see the health and well-being boards as something that will draw together-which they can-all that expertise. But if they cannot and do not have the power to do anything to join up those things, they are the lever that will destroy all this.
Angela Mawle: I agree with you, but if we are looking at a new era, which is how I always try to look at it, it is an opportunity to join people up with a common purpose and with powers to go with it. You talk about commissioning. Commissioning has not been done that brilliantly in the past. It is a foreign subject to most people, even in the health service. If you talk to the public about commissioning, they don’t know about it and just turn off. What I am trying to say to you is that if we can re-fashion the structures that are there now to make them more usable for the public, and for those people who have the expertise and can feed in the information and then give it the power, we could make it work. I quite agree with you that it could be seen as a talking shop, but the concept is great. The partnership working, the collaboration and people being able to do this is very risky because they are not generally very good at it and, as David said, they just become talking shop after talking shop. If you could genuinely create now, in this new generation of practitioners and community, something that is fit for purpose out of the mixture of what you have suggested, with a local commissioning board, and make that somehow answerable or interrelated to the health and well-being board, that would be so effective. It would bring people in to understand the process.
Talking about local data, we heard about the PHOs and how important local data is, but the public do not ever access that. I sometimes had trouble accessing it as a health worker foraging through the system. What the good public health person or GP in their community would be doing is to say, "Here is the information, here is the board, here is the public. What are we going to do about our community?" To create that commonality and joint sense of purpose, you have to give them the opportunity to be not just a talking shop. That is what I am saying.
Q61 Rosie Cooper: It is just very dangerous as it is currently because it will destabilise everything if it remains and does nothing.
Angela Mawle: I agree.
Professor Hunter: I absolutely agree.
Q62 David Tredinnick: I would like to ask a few questions about emergencies. The Government’s plans include significant provisions for major disease outbreaks. I would like to ask Professor Davies about what the Faculty of Public Health has said. It is argued that Public Health England must be a category 1 responder under the Civil Contingencies Act 2004 as the Health Protection Agency currently is. Can you explain this thinking, please?
Professor Davies: Yes. Category 1 responders are those who are at the front line of the response when disaster strikes. There are all sorts of duties for them, but one of them is that they need to cooperate and work with other category 1 responders. That makes a very powerful response. We think that if Public Health England is going to be the organisation that has within it all the public health expertise, or a lot of it, and it is charged with the duty of supporting local authorities to discharge their health protection responsibilities, Public Health England really does need to be designated as a category 1 responder-somebody acknowledged as having responsibilities to respond and to cooperate with others when disaster strikes.
Q63 David Tredinnick: The Faculty of Public Health says that there is lack of clarity on the accountability of Public Health England and local authorities and that this "puts the health of the public at serious risk, particularly in emergency or epidemic situations." Can you explain why that is, please?
Professor Davies: One of the fundamental principles of effective emergency planning and response is that people have to know what they are expected to do and they have to know who is in charge. All parties need to work cooperatively and they need to accept the direction and leadership of the person or the organisation that is in charge. That needs to be something, ideally, that reflects the way in which things work on a daytoday basis, because another principle of emergency planning is that you don’t suddenly do something totally different in an emergency. It is much better to base your emergency response on things that you are used to, working with people whom you are used to, with plans that, between you, you have developed over time. As the current proposals are cast and the responsibilities are described, it is very difficult to see who, in any one situation, would be in charge because local authorities are described as being responsible for the health protection of their population and so is Public Health England, in some circumstances.
There will, of course, be times of national or very significant local disaster or emergency when it is important that the Secretary of State is able to say, "Okay, I am going to take charge. This is so important that I have to be able to see top to bottom in the system and I will direct Public Health England to direct the local authority," or whatever. That is entirely reasonable. But, for the general run of things, it needs to be understood that the local authority is in charge and Public Health England will support it-whether there is an outbreak, an epidemic, a flood or whatever it is locally-so that it can then take a lead in the planning and preparation and so that, when the emergency arrives, everybody knows who is doing what.
Q64 David Tredinnick: The Secretary of State is proposing that he has extensive powers under the Bill to direct emergencies if necessary. Do you think that is a good thing?
Professor Davies: It is important that somebody does, given that the system is going to be very fragmented. There is a risk that unless there are those powers vested somewhere, we will end up with a lot of time and resource wasted by not being able, for example, to persuade providers of care that they should let some of their staff come and work with other providers to fill gaps or whatever. It is important that someone is able to do it if you have a system where there are all sorts of different providers-
Q65 David Tredinnick: There will be civil contingency exercises and surely, soon after the new arrangements are brought into place, you will see where the problems are. Is it really going to be that difficult? Under a new system, won’t it naturally shake down?
Professor Davies: I would love to believe that that is how it would happen. I hope very much that that it is how it would happen and that everybody would act in the best interests of the communities in the situation, but there might be times when priorities are really very different for different organisations in different situations. At that sort of time, it is important that somebody external is able to say, "This has to happen. Now everybody get together and do it." My experience most recently was as director of pandemic influenza in the Department of Health. We had many exercises for that across the country and there was lots of learning, both in the exercises and when we had the pandemic-fortunately, not a severe one. It was very clear that when thinking through initially how NHS hospitals and private sector hospitals would work together in an emergency, for example, some private sector organisations were really keen to offer their staff and their resources to support the NHS and others were absolutely not inclined to do so.
Q66 David Tredinnick: On that specific point, do you think you ordered too much flu vaccine?
Professor Davies: I couldn’t possibly comment.
Q67 Grahame M. Morris: Before we move on, I have a really quick question because you raised exactly the point I was interested in. I am thinking about the practicalities of how it worked in our region in the northeast and the role that the SHA-the strategic health authority-played when there was some doubt about where the distribution centres would be. What are the implications now that the SHAs are going, in terms of saying, "No, there will be a distribution centre in Tyneside, Wearside, Teesside, Weardale"? Who is going to take charge of that? It needs an organisation or an individual if it is a national outbreak like a flu pandemic.
Professor Davies: I am very worried about that. I know that, sitting as I did and colleagues did at the Department of Health, both during the preparation and the response, how the people working in the strategic health authorities and in the local resilience forums took this forward and really made things happen locally. They have the relationships, they can make things work and they know where their things should be. Similarly, the Health Protection Agency’s local units and their regional directors did a fantastic job in setting up the initial response centres. Whatever system we put in place, we have to make sure that there is the ability not just to have the right line of sight and the relationships and trust locally, but also, somewhere in the system, a locus that is not too distant.
Chair: Thank you for that. We have a concluding set of questions on professional regulation.
Q68 Valerie Vaz: I am sorry that we are making you work very hard. I will be breaking all the rules on questions by asking a threeheaded one, but it might help in terms of your answer. First, what is happening with the public health work force at the moment? What is morale like? Secondly, how do you see their role in future under the new system? Thirdly, could you comment on Dr Scally’s review on training? Everybody else can comment afterwards if they want to.
Professor Davies: I have quick answers on both and I can expand them if you like. In terms of morale at the moment, it is very low indeed. People are exhausted. A year ago they were really enthusiastic, encouraged by the fact they were told Christmas was coming early for public health. This new emphasis by the Government on public health is really welcome. There is no doubt about that and it is very, very good, encouraging and heartening for everybody in the work force to see that. However, when you have such a major change in every system going on at the same time and you have the cuts that need to be made in terms of funding, directors of public health, consultants and specialists are telling me that they are hardly able to spend time on the day job of improving the health of the population at the moment. They are spending all their time on HR, on thinking where they are going to go and on managing staff in very difficult circumstances. We know that the cuts are having an impact. For example, they have lost a lot of the support that they were getting from the regional teams, which have gone, and the national support teams have gone. That is causing them, across the country, to have to do more on their own than they did, and a lot of them do not have the resource or the energy anymore to do it. I have enormous respect for how they are carrying on-just keeping their heads up and doing their best-but I really feel for them and I hear from them every day.
The worry at the moment, though, is that that is beginning to turn into not just frustration and exhaustion, but anger at the continuing uncertainty. Although the pause in some ways is good for people to reflect-again, they are encouraged that considered thought is being given to what is being done-for them it is putting further delay and uncertainty into what they are going to do.
Trainees in public health are in a particularly difficult situation at the moment. There are those who will come to the end of their training because they have timelimited training posts, and they can see the abyss of unemployment, frankly. We have invested huge amounts of money and effort into getting the brightest and best to come and go for it in public health, but of course jobs are not being advertised at the moment. The faculty has to approve all the job descriptions to make sure that things like the right standards are being required, but we are seeing hardly any. Who would recruit at the moment? There is nowhere for the trainees to go into. We are trying to get some help for them. It would be good if there could be funding supplied to extend their training for that little bit longer and to give them the confidence to stay on, but we haven’t been able to negotiate that yet. It remains a real problem. Yes, there are real worries and a fragility in terms of what we will have to support-what comes next-in this exciting new world that we are trying to put in place.
Of course, the people working in health care public health are particularly anxious about where they might be and how they are going to have a future because they don’t see themselves acknowledged in any of the reports or the Bill. But, we are hoping. As you say, we have models and we can see a way forward on that. Morale, however, is not great.
On the role of the work force going forward, we have spoken about that a little already, and I can elaborate on particular issues if you like. We are particularly concerned that, going forward, there will still be in this country, as there is at the moment, an internationally recognised specialist and practitioner work force in public health. We are really well respected for having that, and others can talk about it. Focusing on the specialist work force, we need to understand that many specialists in public health work in all three domains at the moment. It is quite unusual for somebody to do only the health improvement bit or only the health service bit, and that is where a lot of the strength comes because you understand all of it. Assuming that you can artificially divide people and put them in different places will mean that you end up with a number of the links being very wobbly, at least in the short term. That said, once things are settled down and there is a vision that people can all work around, they will be up for making that happen and putting their backs into it to support this new drive to improve the public’s health.
Who forms part of the specialist work force and how can the public be confident in the advice that they are getting and the advice that local authorities, Ministers and others are getting? We think that it is very important, as Gabriel Scally recommends, that there is statutory regulation for all specialists in public health. You shouldn’t be able to be a specialist in public health unless you are on a statutory register, and that should be legal. At the moment, if you are a doctor and you want to work in public health, you have to do your medical training, get on to the medical register, do postgraduate training and then be put on the specialist register for the GMC, or as a dentist for the GDC. That is the law. It is statute. If you are not a doctor, you can do exactly the same training-Fiona is the expert on this-and there are a number of other routes by which you can get on to a voluntary register. That is fantastic. It is there and putting that voluntary register in place over the last few years has been a huge achievement, but it does not have the ring of statute around it. It is possible at the moment, as I mentioned earlier, in the Bill, for example, for a director of public health to be appointed who was not on a statutory medical or dental register and not on the voluntary register-not on any register. Given that, to all intents and purposes, although they may come from a range of professional backgrounds, they are essentially the physician to the population who is taking decisions and giving advice that can impact hundreds of thousands of people, it seems to us to be a dangerous thing to say that they do not need to be qualified to do the job. It is a matter of public protection in just the same way as you would not want your heart surgery done by somebody who was not on the statutory register. We do think there needs to be a statutory requirement for registration for public health specialists.
Q69 Chair: Would anyone else like to comment on those issues?
Professor Hunter: There has been some concern that the Scally report has upset the wider public health workforce-those specialists and practitioners who come from a multidisciplinary background and who have been keen to promote that. The report has been perceived as destabilising and undermining what the voluntary register has achieved. As Lindsey said, it has been a great success in many ways. People are unclear why the Scally report came out in favour of a statutory model based on the Health Professions Council, which has no history of doing public health regulation. The fear is it would adopt a narrow medical onesizefitsall model that would not reflect the wider interests in public health. Far from going forward, we are in danger of going back in terms of public health being seen to be a predominantly medically qualified clinical specialty. So there is fear about that. Rightly or wrongly, that is the concern out in the field and this uncertainty, at the moment, is again a further factor making for destabilisation and low morale among those in training or in the profession. So it is a concern, I think.
Dr Sim: As far as the work force are concerned, the changes-the reforms-are already happening so part of the low morale is the reality that budgets are being cut. Where clusters of PCTs are forming, it is not uncommon-certainly in London it has already happened-that the number of directors of public health has been reduced to reflect the clusters rather than the PCTs, so people’s jobs are already threatened and that is not helping morale, clearly. At the moment, they have been slotted in as consultants, but obviously the future is very vague.
There has also been a loss of the front-line troops who are not protected in terms of their job titles, although they work full time in public health-for example, people who are providing smoking cessation services. Some of those have disappeared completely as part of the budgetary reductions, and that is another thing affecting the morale of the specialists because they have no front-line colleagues to deliver health-improving interventions. It is also clearly going to have an impact on the health of the population because those interventions are no longer being delivered by those people who have been doing so. Therefore, there are real issues about ongoing reforms that have little to do with what we are talking about in terms of the futures. They have already cut quite deep in many places, and that is in addition to the future uncertainty.
As far as regulation is concerned, when I was at the Department of Health, I was responsible for establishing the voluntary register for public health specialists. It was set up with a view to becoming statutory in due course, so, at a personal level, I do have an understanding that there should be-as there always was-a view that all public health specialists doing equivalent jobs to people on the medical specialist register should be registered in a way that is entirely equivalent. The voluntary register has made great strides in going in that direction. It is effective as a voluntary register and could continue to perform that function for years to come. It does need the support, however, of employers being required to appoint people who are on the register, which is the case. There has been guidance to the NHS for many years-and I cannot remember the year that the letter came out, but I think it was about 2005 or maybe 2004-that requires NHS employers to appoint people to consultant posts or director of public health posts who are on the GMC, the GDC or voluntary registers at specialist level.
Thus, moving to local government, even without changing the regulatory framework, there is great uncertainty as to what would be permitted by way of appointments. The Royal Society for Public Health has, in its response to the White Paper, put in a proposal to create a charter status to strengthen voluntary regulation as a possible middle way rather than going all the way to setting up either a new statutory register or coming under the wing, as I think David has mentioned, of the HPC or another existing register that may or may not be fit for purpose.
Angela Mawle: Very briefly, we totally support a multidisciplinary approach. We tend to feel that we are tinkering with 20th century structures that are not fit for purpose for the 21st century. We produced a report on health visiting. Health visitors are broad public health practitioners, to some extent, although they are currently employed in the NHS. It looked at widening the entry gates and at a new professional entry and professional development for that work force. It led us to think that the same could be done for all people entering public health and that now is the time, if we are going to look at these systems. Clearly what works now is good and efficient, and the voluntary register is doing a very good job, but it still seems to me that you are creating another sanctum within a sanctum, or an external sanctum, of a largely medical model because it is very specialised-even the voluntary register. That is not to say that you need that particular specialism in the tool box, but in terms of Marmot’s report and the coming difficulties of this century, we are struggling with looking at it in the mechanistic way and seeing that there should be a rootandbranch review of what the public health work force should look like in 10 to 15 years’ time and what it will have to deal with and, therefore, how we create career structures for bright young things now to come forward and pick up on these huge challenges.
Professor Davies: I have one very quick point, if I may. On the general view of the work force in public health on statutory regulation, we are a multidisciplinary specialty and we surveyed our members earlier in the year on what they thought about that. The overwhelming response was that they wanted statutory regulation; they all want to be the same. One can understand that, and the risk is almost like saying that as doctors are registered already, they want to be sure that local authorities or whoever don’t say, "I will have the doctor because I know what that is." We need to be sure there is a clear ring of confidence around the specialist work force in total.
As to the advisory appointments committee, as Fiona has said, that really is an important point: in the NHS you can be appointed only to a consultant specialist, DPH post through a statutory committee set up in the right way with the right content and with advisers and so on around it to ensure that standards are there. The statutory instrument does not apply anywhere other than in the NHS. It does not apply in the civil service and it does not apply in local authorities, and we would like to see that extended to make sure that standards are maintained and the public can be confident.
Chair: On that note, thank you very much. We have covered a huge amount of ground this morning at a fairly brisk pace, but it has been a very useful session. Thank you very much for coming.